Bọng đái thần kinh
I. ĐỊNH NGHĨA: Bọng đái rối loạn chức năng do bệnh lý thần kinh
trung ương hoặc ngoại biên.
II. TỪ KHÓA: anticholinergic, thông tiểu, khả năng giãn nở bàng
quang, áp lực đồ bọng đái, soi BQ, tk vận động, giao cảm và phó giao cảm, ứ nước
thượng nguồn, suy thận do trào ngược, chuyển lưu nước tiểu ra da.
III. NGUYÊN NHÂN:
A. BỆNH TỦY SỐNG: chấn thương, ung thư (nguyên phát hoặc thứ phát),
thoát vị đĩa đệm, bệnh lý nội khoa của tủy sống, dị tật ống tủy, cột sống chẽ đôi…
B. NÃO: u não, TBMMN,
C. THẦN KINH NGOẠI BIÊN: sau mổ vùng chậu ( sacrococcyceal
teratoma)…
IV. SINH LÝ:
A. PHA ĐỔ ĐẦY:
B. PHA TỐNG SẠCH
V. SINH LÝ BỆNH:
A. Brain lesion
Lesions of the brain above the pons destroy the master control center, causing a
complete loss of voiding control. The voiding reflexes of the lower urinary tract—
the primitive voiding reflex—remain intact. Affected individuals show signs of
urge incontinence, or spastic bladder (medically termed detrusor hyperreflexia or
overactivity). The bladder empties too quickly and too often, with relatively low
quantities, and storing urine in the bladder is difficult. Usually, people with this
problem rush to the bathroom and even leak urine before reaching their
destination. They may wake up frequently at night to void.
Typical examples of a brain lesion are stroke, brain tumor, or Parkinson disease.
Hydrocephalus, cerebral palsy, and Shy-Drager syndrome also are brain lesions.
Shy-Drager syndrome is a rare condition that also causes the bladder neck to
remain open.
B. Spinal cord lesion
Diseases or injuries of the spinal cord between the pons and the sacral spinal cord
also result in spastic bladder or overactive bladder. People who are paraplegic or
quadriplegic have lower extremity spasticity. Initially, after spinal cord trauma, the
individual enters a spinal shock phase where the nervous system shuts down. After
6-12 weeks, the nervous system reactivates. When the nervous system becomes
reactivated, it causes hyperstimulation of the affected organs. For example, the
legs become spastic.
These people experience urge incontinence. The bladder empties too quickly and
too frequently. The voiding disorder is similar to that of the brain lesion except
that the external sphincter may have paradoxical contractions as well. If both the
bladder and external sphincter become spastic at the same time, the affected
individual will sense an overwhelming desire to urinate but only a small amount of
urine may dribble out. The medical term for this is detrusor-sphincter dyssynergia
because the bladder and the external sphincter are not in synergy. Even though the
bladder is trying to force out urine, the external sphincter is tightening to prevent
urine from leaving.
The causes of spinal cord injuries include motor vehicle and diving accidents.
Multiple sclerosis (MS) is a common cause of spinal cord disease in young
women. Those with MS also may exhibit visual disturbances, known as optic
neuritis. Children born with myelomeningocele may have spastic bladders and/or
an open urethra. Conversely, some children with myelomeningocele may have a
hypocontractile bladder instead of a spastic bladder
C. Sacral cord injury
Selected injuries of the sacral cord and the corresponding nerve roots arising from
the sacral cord may prevent the bladder from emptying. If a sensory neurogenic
bladder is present, the affected individual may not be able to sense when the
bladder is full. In the case of a motor neurogenic bladder, the individual will sense
the bladder is full and the detrusor may not contract, a condition known as
detrusor areflexia. These individuals have difficulty eliminating urine and
experience overflow incontinence; the bladder gradually overdistends until the
urine spills out. Typical causes are a sacral cord tumor, herniated disc, and injuries
that crush the pelvis. This condition also may occur after a lumbar laminectomy,
radical hysterectomy, or abdominoperineal resection.
Some teenagers suddenly develop an abnormal voiding pattern and often are
evaluated for tethered cord syndrome, a neurologic condition in which the tip of
the sacral cord is stuck near the sacrum and cannot stretch as the child grows
taller. Ischemic changes of the sacral cord associated with the tethering cause the
manifestation of dysfunctional voiding symptoms
D. Peripheral nerve injury
Diabetes mellitus and AIDS are 2 of the conditions causing peripheral neuropathy
resulting in urinary retention. These diseases destroy the nerves to the bladder and
may lead to silent, painless distention of the bladder. Patients with chronic
diabetes lose the sensation of bladder filling first, before the bladder
decompensates. Similar to injury to the sacral cord, affected individuals will have
difficulty urinating. They also may have a hypocontractile bladder.
Other diseases manifesting this condition are poliomyelitis, Guillain-Barré
syndrome, severe herpes in the genitoanal area, pernicious anemia, and
neurosyphilis (tabes dorsalis).
VI. TRIỆU CHỨNG:
1. Nhiễm trùng tiểu tái đi tái lại (sốt, lạnh run).
2. Sỏi niệu (bàng quang, thận, nq).
3. Tiểu không kiểm soát, mất cảm giác đầy BQ.
4. Suy thận do bọng đái tràn đầy.
VII. CHẨN ĐOÁN:
1. Thể tích nước tiểu sót lại trong BQ > 100 ml sau đi tiểu.
2. Siêu âm đánh giá ứ thận và độ dày thành BQ.
3. Xác định urê máu, creatinin và Kali máu.
4. Soi BQ, đo áp lực đồ BQ.
VIII. ĐIỀU TRỊ:
1. NỘI KHOA:
a. Đặt thông niệu đạo lưu, tập tiểu mỗi 2-3-4h. Thay thông mỗi 2-3 tuần.
b. Chống nhiễm trùng niệu.
c. Tập vật lý trị liệu chi, chống loét, không được bất động.
d. Tham gia hội người tàn tật bọng đái thần kinh.
2. CAN THIỆP:
a. Mở BQ ra da
Mổ đơn giản.
BQ ra da áp lực thấp (có valve là ruột thừa)
Mở rộng thể tích BQ bằng ruột non.
b. Mổ tạo hình cơ thắt BQ nhân tạo.
